Tuesday, January 20, 2009

The supernurse's myth

Here is the executive summary of the last study I published at CIRANO. The complete paper was released on january 19th and is available at: http://www.cirano.qc.ca

The existence of a nursing shortage is now widely recognized and accepted by the vast majority of stakeholders and citizens, but the context in which nurses actually practise their trade remains veiled behind tenacious taboos. In fact, if Quebec nurses functioned at a labour intensity comparable to that of their colleagues elsewhere in Canada and abroad, we might find that a significant share of the nursing shortage was eliminated by means other than training new personnel—though this must remain a key element of any strategy for reducing the shortfall. The purpose of this study is to sketch out the context of the practice and shortage of the nursing workforce in Quebec. Our main findings follow. For more information, please consult the complete study (in French) at http://www.cirano.qc.ca.

-By any standard of comparison—Quebec, Canadian, and International—nurses don’t work very muchIn 2007, Quebec nurses averaged 28 effective hours of work per week. In contrast, employees of the Quebec public service worked an average of 30.2 effective hours per week (7.9 % more than nurses) while the mean for the federal civil service was 31.3 hours per week (11.8 % more) in 2008.The labour intensity of Quebec nurses is also below that of their colleagues in the rest of Canada. Nurses in Ontario work an average of 31.3 hours, while in the ROC this number is 30.9 hours. This amounts to a difference of 12 % with Ontario nurses and 10 % with those in the ROC. This number of hours includes all employed nurses, whether or not they were working at the time of the survey.Among 10 international jurisdictions, aside from Australia it is in Quebec where nurses work the smallest number of contracted hours. For example, in the United States nurses habitually work 38.5 hours on average, 15.2 % more than in Quebec. The corresponding percentages are 13.1 % for the United Kingdom and 6.8 % for France (see graphique 6).[2]- They do not work more overtime than nurses elsewhere in CanadaIn 2007, while Quebec nurses worked an average of 1.76 overtime hours per week, the corresponding value was 1.77 in Ontario and 1.8 in the ROC (see graphique 7).- The myth of the “super-nurse” is largely hyperbole: 0.9 % of nurses work 500 or more hours of overtime in a year (or 9 hours per week in FTE). This amounts to 628 nurses out of a workforce of nearly 70,000!

Data from the MSSS (le Ministère de la Santé et des Services sociaux, Quebec’s Ministry of Health and Social Services) reveals that 83.1 % of the nursing workforce puts in less than 100 overtime hours annually (1.9 hours per week in FTE) and that 0.9 % works over 500 hours of overtime per year (9.6 hours per week in FTE). Thus, the ministry finds that the median value of overtime hours (19 hours per year) is far below the mean.[3] This data suggests that there are 628 “super-nurses” among the 69,765 nurses belonging to OIIQ.

- The likely causes of the low work intensity of nurses is: a greater proportion of part-time work than in other sectors …

Except during the period 1999–2000, the proportion of full-time nurses has always been lower in Quebec than in Ontario and, compared to the ROC, Quebec has always had proportionally fewer nurses working full time. However, like in Ontario and the ROC, the proportion of full-time nurses has grown steadily since 1997 (see graphique 8).

It is worth noting that 15.3 % of Quebec nurses who were working part time did so because they were unable to find full-time work or for other reasons related to labour market conditions. Among nurses under 35 years of age, this proportion falls to 21.2 %, meaning that more than one nurse in five at the beginning of their careers were unable to find a full-time job.

- … And more frequent and longer absences.

In monthly data gathered by LFS for 2007, 17.5 % of Quebec nurses declared themselves employed but absent from work, compared to 11.4 % in Ontario and 12.6 % in the ROC. From 1997 to 2007, this proportion generally remained between 14 % and 18 % in Quebec and between 12 % and 14 % in the ROC (See graphique 9). It is important to note that these absences were due to injuries and illnesses as well as holidays and annual vacations.

When they were longer than one full week, the spells of absence of Quebec nurses also outlasted those in other Canadian provinces: 15.5 weeks on average versus 12.6 in Ontario and 12.2 in the ROC (See graphique 10).

Overall, Quebec nurses work long hours when they are on the job. Allocating the 1462 hours annually to 36.5 weeks present on the job yields the equivalent of 40 hours worked per week. However, expressing the nurses’ work effort like this conceals a conceptual flaw: In a sense, it is equivalent to implying that Quebec’s healthcare system only operates at full capacity 36.5 weeks per year. In short … that it is shut down the remaining 15.5 weeks. This is unreasonable.

- The edge Quebec nurses enjoy over the rest of the population in comparisons of wage conditions and the wealth gap has always lagged behind the corresponding values in Ontario and the ROC, but this discrepancy has been growing since 2003.

That is not to say that Quebec nurses want to work less than their colleagues in the ROC, however. They are simply responding to the institutional and pecuniary incentives offered to them.

Until 2003, the real hourly wage of Quebec nurses was comparable to that of nurses in the ROC. As of 2003, however, the hourly compensation to Quebec nurses has increasingly diverged from that paid to nurses in the ROC, to the point that, in 2007, the mean hourly wage of Quebec nurses was no more than 86.9 % of the mean hourly wage of nurses in other provinces ($4.43 less in real terms). In 1997, the difference between these two hourly wages was $0.03 in real terms!

While nurses in Ontario were earning 145 % of the mean wage of that provinces’ population in 2006, their Quebec counterparts only received 137.5 % of Quebeckers’ mean wage (148.6 % for the ROC). This means that Quebec’s nurses do not enjoy the same standard of living premium over the population as a whole as do other nurses in Canada (See graphique 12).

- The shortfall computed by the MSSS is not real: The normal definition of a shortage is a discrepancy between the quantity supplied and the quantity demanded

As the method described in the document explains, the shortfall as calculated by the MSSS does not correspond to the traditional definition of a shortage, because it ignores the demand for healthcare services.Thus, the conceptual framework of their calculations centres on containing or reducing nurses’ workloads rather than increasing healthcare services to the population. Since only overtime hours are accounted for in the determination of the extent of the shortage, the needs reflected by the Ministry’s method of calculation are designed to eliminate excessive overtime hours. However, if all we want to do is eliminate an excess of overtime hours, we will not be providing any additional services to the population.

- The methodological choices of the MSSS for computing the shortage result in an overestimation of 17 %

Since the MSSS expresses the shortfall in terms of the effective workload the data they publish on the shortfall are overestimated because they do not represent the real work performed by nurses.One method that would yield a more representative snapshot of the practical reality of the nursing workforce, as a first approximation, would be to express the shortage in terms of the effective workload. This would capture the real work effort provided by Quebec nurses, including overtime hours and absences, which the current method does not. This procedure, though flawed because it might not account for what is needed to satisfy the demands of the healthcare system, would be a methodological improvement in that it expresses the shortage as a function of hours effectively worked, and not only in terms of regular working hours. This would have the effect of reducing the shortage by between 16 % and 18 %, depending on the region.This choice is all the more appropriate to the extent that the hours effectively worked by Quebec nurses are lower than those of their colleagues in the ROC. Thus, an increase in the work intensity of Quebec nurses would contribute to reducing the shortage.

- If we were to match the labour intensity of Ontario nurses, the shortage as expressed by the MSSS would decline by 25.4 % (–10 % for the “corrected” shortfall).

Scenario 2 would raise the number of annual effective hours to an average of 1634.8. Reaching the goal of Scenario 2 would reduce the shortage, in its current form, by 458 individuals, or 25.4 %, if we include the methodological correction. In view of the corrected shortfall, the increased labour intensity described by scenario 2 would allow recruitment needs for the entire province to be reduced by 10.6 %. Reaching the targets of scenario 2 would certainly require an increase in the proportion of nurses working full time to levels comparable to those in Ontario.

- There are many ways to increase the intensity of labour: improving compensation (especially for those coming out of retirement), encouraging part-time nurses to mix public and private sector employment (one young graduate in five is working part-time for lack of a full-time job), the creation of full-time jobs, auctions of free shifts in the very short term (momentary absences), etc.